Polydipsia

Polydipsia
ICD-10	R63.1
ICD-9	783.5

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Overview

Polydipsia is a medical condition in which the patient ingests abnormally large amounts of fluids by mouth. The word is made from the words poly meaning many and dipsia which means thirst. The fluid is usually water, though some people may think of alcohol because of the etymologically related term dipsomaniac, meaning an alcoholic.

Differential diagnosis of the causes of polydipsia

Common causes

Polydipsia is almost always associated with dehydration due to polyuria (excessive urination), if the condition is prolonged beyond a few hours in those with functioning kidneys.

It is often, and characteristically, found in diabetics, often as one of the initial symptoms, and in those who fail to take their anti-diabetic medications or whose dosages have become inadequate. It is also caused by other conditions featuring osmotic diuresis and by diabetes insipidus ("water diabetes"), and forms part of the differential diagnostic tree for them, as well. Polydipsia is also a symptom of atropine or belladonna poisoning. Another cause can be due to medication (such as diuretics) or inadvertent consumption of caffeine. One who drinks nothing but coffee or soda can be easily misdiagnosed by a medical professional as psychogenic polydipsia, as they may be unaware they are consuming diuretics.

Complete differential diagnosis of causes of polydipsia

(In alphabetical order)

• Beer potomania
• Cushing syndrome
• Diabetes insipidus
  • Nephrogenic diabetes insipidus
    • Amyloidosis of the kidneys
    • Amikacin
    • Amphotericin B
    • Bardet-Biedl syndrome
    • Bartter syndrome
    • Cystinosis
    • Demeclocycline
    • Diabetes insipidus, congenital nephrogenic
    • [Fanconi syndrome]]
    • Gentamicin
    • Hypercalcaemia
    • Hypokalaemia
    • Interstitial nephritis
    • Kanamycin
    • Lithium
    • Loken Senior syndrome
    • Medullary cystic renal disease
    • Multiple myeloma
    • Netilmicin
    • Polycystic kidney disease, adult (autosomal dominant)
    • Proximal renal tubular acidosis
    • Pyelonephritis, acute
    • Renal failure, acute
    • Renal failure, chronic
    • Sicca syndrome
    • Sickle cell disease
    • Urinary tract infection
  • Central diabetes insipidus
    • Arteriovenous malformations or aneurysms
    • Cranial surgery
    • Craniopharyngioma
    • Cysts
    • Cysticercosis, cerebral
    • DIDMOAD syndrome
    • Erdheim-Chester disease
    • Gestational diabetes insipidus
    • Head injury
    • Histiocytosis X
    • Hydrocephalus, obstructive
    • Hypoxic encephalopathy
    • Intracranial space-occupying lesion
    • Leukemia, acute
    • Meningioma
    • Meningoencephalitis
    • Meningitis
    • Metastatic brain disease
    • pineal tumors
    • Pituitary tumor
    • Post encephalitis status
    • Radiation therapy
    • Sarcoidosis
    • Sheehan syndrome
    • Sickle cell disease
    • Skull fracture
    • Syphilis
    • Tuberculosis
    • Tuberculoma of the hypothalamus
• Diabetes mellitus type 1 or type 2
• Hyperaldosteronism
• Hyperglycemia
• Hyperthyroidism
• Maturity onset diabetes of the young
• Medications especially diuretics. see also nephrogenic diabetes insipidus
  • Bendrofluazide
  • Bumetanide
  • Conivaptan
  • Furosemide
  • Hydrochlorothiazide
  • Lithium
  • Vasopressin
  • atropine
  • belladonna poisoning
  • caffeine
• Nephronophthisis
• Osmotic diuresis
  • Diabetes mellitus
  • Hyperglycaemia
  • Isosorbide
  • Mannitol
  • Sorbitol
• Primary hyperparathyroidism
• Psychogenic polydipsia
• Sicca Syndrome
• Water intoxication

Complete differential diagnosis of the causes of polydipsia

(By organ system)

Cardiovascular	Arteriovenous malformations or aneurysms (vascular)
Chemical / poisoning	belladonna poisoning,
Dermatologic	No underlying causes
Drug Side Effect	Bendrofluazide, Bumetanide, Conivaptan, Frusemide,Hydrochlorothiazide, Lithium, Vasopressin, atropine, belladonna poisoning, caffeine, Amikacin, Amphotericin B,Demeclocycline, Gentamicin
Ear Nose Throat	No underlying causes
Endocrine	Cushing syndrome, Primary hyperparathyroidism, Hyperglycemia Diabetes insipidus, Water intoxication, Hyperthyroidism, Maturity onset diabetes of the young, Diabetes mellitus, Antidiuretic Hormone
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	Polycystic kidney disease(autosomal dominant), Congenital nephrogenicDiabetes insipidus, Bardet-Biedl syndrome, Sickle cell disease, DIDMOAD syndrome, Fanconi syndrome
Hematologic	Sickle cell disease
Iatrogenic	Radiation therapy
Infectious Disease	meningoencephalitis, Syphilis, Tuberculosis, Meningitis, Cysticercosis (cerebral), Post encephalitis status, Tuberculoma of the hypothalamus
Musculoskeletal / Ortho	No underlying causes
Neurologic	Craniopharyngioma, Pineal tumors, Hypoxic encephalopathy, Pituitary tumour, Metastatic brain disease, Meningioma, Hydrocephalus, (obstructive)
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	Gestational diabetes insipidus, Sheehan syndrome
Oncologic	pineal tumors, Craniopharyngioma, Histiocytosis X,Pituitary tumour, Leukemia(acute), Metastatic brain disease, Meningioma
Opthalmologic	No underlying causes
Overdose / Toxicity	Beer potomania, Water intoxication
Psychiatric	Psychogenic polydipsia, Beer potomania
Pulmonary	No underlying causes
Renal / Electrolyte	Bardet-Biedl syndrome,Bartter syndrome,Cystinosis, Congenital nephrogenicDiabetes insipidus, Hypercalcaemia, Hypokalaemia, Interstitial nephritis, Loken Senior syndrome, Medullary cystic renal disease, Polycystic kidney disease(autosomal dominant), Proximal renal tubular acidosis,Pyelonephritis,Renal failure, Urinary tract infection
Rheum / Immune / Allergy	Sarcoidosis, Amyloidosis
Sexual	No underlying causes
Trauma	Head trauma, Skull fracture
Urologic	No underlying causes
Miscellaneous	Sarcoidosis, Histiocytosis X

Polydipsia in Psychiatric Subsets

Psychogenic polydipsia is a type of polydypsia with described in patients with mental illnesses and/or the developmentally disabled. It is present in a subset of schizophrenics. These patients, most often chronic schizophrenics with a long history of illness, often exhibit enlarged ventricles and shrunken cortex on MRI, making the physiological mechanism difficult to isolate from the psychogenic. It is a serious disorder and often leads to institutionalization as it can be very difficult to manage outside the inpatient setting. It should be taken very seriously - it can be life threatening as serum sodium is diluted to an extent that seizures and cardiac arrest can occur. Patients have been known to seek fluids from any source possible.

In treatment resistant polydipsic psychiatric patients, regulation in the inpatient milieau can be accomplished by use of a weight-water protocol. First, baseline weights must be established and correlated to serum sodium levels. Weight will normally fluctuate during the day, but as the water intake of the polydipsic goes up, the weight will naturally rise. The physician can order a stepped series of interventions as the weight rises. The correlation must be individualized with attention paid to the patient's normal weight and fluctuations, diet, co-morbid disorders (such as a seizure disorder) and urinary system functioning. Progressive steps might include redirection, room restriction, and increasing levels of physical restraint with monitoring. Such plans should also progressive increases in monitoring, as well as a level at which a serum sodium level is drawn.

It is important to note that the majority of psychotropic drugs (as well as many of other classes) can cause dry mouth, but this is not to be confused with true polydipsia in which a dangerous drop in serum sodium will be seen.

While psychogenic polydipsia is generally not found outside the population of those with serious mental disorders, there is some anecdotal evidence of a milder form (typically called 'habit polydispsia' or 'habit drinking') that can occasionally be found in the absence of psychosis or other mental conditions. The excessive levels of fluid intake may result in a false diagnosis of diabetes insipidus, since the chronic ingestion of excessive water can produce diagnostic results that closely mimic those of mild diabetes insipidus.

Diagnosis

Polydipsia is a symptom, not a disease (cause). To diagnose the cause of polydipsia a fluid deprivation test is used, which may require a patient to abstain from water, and for blood and urine tests to be undertaken. Additional blood work may be required to test for the presence of diuretics, such as caffeine, or recreational drugs. Finally neurological testing may be required to determine if there has been damage to the hypothalamus ( central diabetes insipidus). These tests are routinally used in diagnosing diabetes insipidus.

Treatment

Most patients with diabetes insipidus (DI) can drink enough fluid to replace their urine losses. Losses can also be replaced with dextrose and water or IV fluid hyposmolar to the patient's serum. During replacement, avoid volume overload and a correction of hypernatremia that is too rapid. A good rule of thumb is to reduce serum sodium by 0.5 mmol/L/h. Water deficit may be calculated based on the assumption that body water is approximately 60% of body weight in kilograms. In case of inadequate thirst, desmopressin is the drug of choice. Generally, it can be administered 2-3 times per day. Patients may require hospitalization to establish fluid needs. Frequent electrolyte monitoring is recommended. Vasopressin or desmopressin acetate, modified synthetic forms of antidiuretic hormone, may be taken as a nasal spray several times a day, to maintain a normal urine output. However, taking too much of this medication can cause fluid retention and swelling and other problems. Sometimes diabetes insipidus can be controlled with drugs that stimulate production of antidiuretic hormone such as chlorpropamide, carbamazepine, clofibrate. If nephrogenic DI is caused by medication (for example, lithium), stopping the medication may help restore normal kidney function. However, after many years of lithium use, the nephrogenic DI may be permanent. Hereditary nephrogenic DI and lithium-induced nephrogenic DI are treated by drinking enough fluids to match urine output and with drugs that lower urine output. Drugs used to treat nephrogenic DI include: Anti-inflammatory medication (indomethacin)and Diuretics (hydrochlorothiazide (HCTZ) and amiloride).

Johnfanisrour 19:14, 25 January 2009 (UTC) John Fani Srour Johnfanisrour 19:14, 25 January 2009 (UTC)